Starting point for a specification for a composition of a Structured Document.

Universal starting point for specifying a FHIR Clinical Document.

Authorization Extension refers to a FHIR Consent instance that indicates a patient’s consent

The Data Enterer Extension represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author’s information to the electronic system.

Document Identifier provides the sender-specific identifier. The system provides the namespace where the identifier is unique. Value provides the identifier. Note that both are needed to positively identify the specific instance (version) of the document. The Composition.identifier element in the ClinicalDocument Profile provides the higher-level set identifier - which indicates to what sequence of clinical documents the specific document belongs. The use of two identifiers may be deprecated in the future given the ability to track changes with relatesTo, effectiveTime, and the Composition.identifier.

Informant Extension describes an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient.

The Information Recipient Extension records the intended recipient of the information at the time the document was created.

The Order Extension represents orders that are fulfilled by this document such as a radiologists report of an x-ray.

Participant Extension identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).

The Performer Extension represents clinicians who actually and principally carry out the clinical services being documented. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patients key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.

Original discharge summary

Replacement discharge summary

Clinical Document Bundle Document Type

Clinical Document Bundle Transaction Type